THE DOWNFALL TEAM PRESENTS BE ON THE BALL PREVENT A FALL! Multi-Disciplinary Team Peggy Benenati Risk Management Beverly Campbell Nursing Kim Cerri Quality Roberta Farley Physical Therapy Kelli Farnell Pharmacy Ryan Nadeau Nursing Joan Osborne Education
PROBLEM SELECTION AND GOAL BHIP Fall Stats FY12: 137 Inpatient falls Rate: 3.2 per 1000 patient days 46 th percentile
PROBLEM STATEMENT Falls Increase Risk! Patient Risks Hospital Risks Cost $16,000 per fall 6.27 more days Sources: The No Fall Zone, Hospital & Health Networks, 6-1-2013; CDC, www.cdc.gov
ROOT CAUSE ANALYSIS AND PROJECT TOOLS SIX SIGMA DMAIC Define, Measure, Analyze, Improve, Control
CHARTER Business Purpose Timeline Problem Goal Cost
Stakeholders CNO Nurse Managers PROJECT LAUNCH Communication Plan Project Status Fall reduction is important! CEO Approval
DEFINE SIPOC CHART Process Suppliers Process Inputs Process Outputs High Level Process Steps Process Customers
PROCESS MAP
MEASURE DATA PROCESS PROBLEM DOES THE EXISTING DATA REPRESENT THE PROBLEM?
SURVEY Random Sample 45 Nurses Inpatient Units All Shifts Likert Scale Multiple Choice Narrative Comments MEASURE
MEASURE Incident report fall data reviewed and compiled Survey data reviewed and compiled DATA PROCESS PROBLEM
ANALYZE Descriptive Statistics 50% of falls occurred during bathroom or toileting activities 20% of patients who fell were not identified at risk
Survey Data ANALYZE Segmented Stratified Grouped By Question Unit Shift Team chose correct answers to measure the survey responses.
ANALYZE INPATIENT FALLS
Incorrect fall risk assessment ANALYZE Contributing Factors Lack of identification of patients at risk for falls Inconsistent use of nursing judgment to initiate the fall prevention protocol Insufficient communication about patients fall risk Lack of patient and family participation in the fall prevention protocol Inconsistent supervision of patients during bathroom and toileting activities Variable bed alarm functionality
PRIMARY ROOT CAUSE! ANALYZE Nurses and patients do not fully understand underlying fall risk factors. Resulting in critical barriers to appropriate fall risk identification and effective fall prevention.
IMPROVE AND CONTROL Strategies to improve and sustain process changes Ensure changes are implemented and adopted as routine
Multifaceted Approach IMPROVE Systematically address each initial root cause Fix the primary root cause! Twofold Intent Enhance nurses understanding of fall risk for better identification Enhance patients and families understanding of fall risk for better compliance
IMPROVE STRATEGIES Fall Risk Hand-Off Communication In-depth, comprehensive Physiologic fall risk factors Weakness, dizziness, fatigue Sensory impairments Mental status Medications
IMPROVE STRATEGIES INTRODUCING. THE ABC S OF INJURY RISK! AGE BONES COAGULATION SURGERY
IMPROVE STRATEGIES Unit Safety Huddles High Fall Risk Patients Discussed
IMPROVE STRATEGIES Comprehensive Post-Fall Evaluation Tool What did the patient / family say? What were the risk factors? What caused or contributed? Was the patient appropriately assessed? Were appropriate interventions in place? What could have been done to prevent the fall? On the spot analysis and learning!
Fall Prevention Critical Concepts IMPROVE STRATEGIES Simple statements about proper assessment and use of the fall prevention process Example: A secondary diagnosis is any diagnosis in addition to the admitting diagnosis.
IMPROVE STRATEGIES Scripted Teach Back Aligned with shift-hand off communication Enhance patient participation in fall prevention Fall risk is part of the patient s medical condition
Scripted Rounding Language Affirmative statement of intent IMPROVE STRATEGIES Encourage patients to use the bathroom Example: I am here to take you to the bathroom.
IMPROVE STRATEGIES RED RULES Supervision during toileting activities Bed alarm activated
IMPROVE STRATEGIES Improve Bed Alarm Functionality Connect bed alarms to Cisco Phones Annual Performance Maintenance for Bed Alarms Wire bed alarms to ring at nursing stations Environmental Services resets bed alarms after making up beds
IMPLEMENTATION HAND-OFF COMMUNICATION Fall Risk Shift Hand-Off 1. Is your patient at risk for fall? 2. What is the Morse Fall Scale score? 3. Has your patient fallen during this hospital stay? When did the fall occur and what were the circumstances? What were the injuries, if any? How was POC modified? 4. What physiologic factors contribute to the risk? Primary and Secondary Diagnoses that cause weakness, dizziness, fatigue, excessive bed rest. Four or more medications associated with falls (CIWA protocol, cardiovascular meds, hypoglycemic agents, psychotropics, muscle relaxants, neuroleptics, opioids, sedatives, sleeping aids, antihistamines). What are the medication interactions? Does the patient have any symptoms or side effects from medications that would increase risk for falls? Mental Status (e.g.: confused, disoriented, combative, doesn t follow directions, lethargic, somnolent). Last time patient was toileted? Sensory impairments - (vision, hearing, touch (e.g.: diabetic neuropathy). Activity level the prior shift - (stayed in bed, up and out of bed, restless). 5. Is your patient at high risk for injury and why? Consider ABCS - Age, Bones, Coagulation, Surgery. Age Increased age- higher risk. Bones- Osteoporosis or other conditions that increase risk of fracture. Coagulation- Anticoagulation therapy that increases risk of bleeding- Coumadin, Pradaxa (this does not include VTE prophylaxis with Lovenox). Surgery - Recent surgery that increases risk of injury hip, knee, abdominal surgery. 6. Recommendations to prevent fall and injury from fall.
IMPLEMENTATION Hand-off Communication and Teach Back Team members modeled hand-off and teach back Unit fall champions Online education
IMPLEMENTATION Critical Concepts Annual competencies Safety Huddles Unit specific implementation Rounding Rounding initiative and live education
Monitor and Sustain Improvements Falls Committee established as subcommittee of the Nursing Quality and Patient Safety Council Committee review of data and recommendations for improvement. Second look in June 2014 Added laboratory initiative for early morning lab draws. CONTROL
40 % REDUCTION Reduced Fall Rate from 3.2 to 1.97 10 th Percentile! SIGNIGICANT COST AVOIDANCE
LESSONS LEARNED Critical thinking is required for accurate fall risk assessment! What you say to encourage patients to use the bathroom really makes a difference! Communicating reasons for fall risk enhances patient and family participation! Consistent communication among the team raises fall risk awareness for better prevention! PI project done with intensity and focus is far more effective than PI projected done with urgency! Successful PI project needs accountability for outcomes among the stakeholders! The process improvement process is just as important as improving the process!
OUR JOURNEY CONTINUES